Provider Demographics
NPI:1558519827
Name:CHILDREN'S HOSPITAL OF MICHIGAN, DETROIT MEDICAL CENTER
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL OF MICHIGAN, DETROIT MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PEDIATRIC RESIDENCY
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-966-0254
Mailing Address - Street 1:4500 CASS AVE
Mailing Address - Street 2:APARTMENT NO. 617, UNIVERSITY TOWERS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1288
Mailing Address - Country:US
Mailing Address - Phone:313-715-0162
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:CHILDREN'S HOSPITAL OF MICHIGAN
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-5638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092198282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren